Getting the truth : a qualitative comparative analysis of rural nurses' attitude to safety climate and their views of reporting a hypothetical medication error

Interventions to prevent error and improve error management have been central to health care safety and quality research. To achieve this, any error needs to be reported formally and should also be acknowledged to the patient/consumer or their family. Appropriate organisational culture is regarded as a means of assisting these actions. Error management is important to the health system, clinicians and most importantly for consumers. When an error occurs it can lead to harm, which itself can be traumatic, but this in turn can lead to increased costs both to the system and to the consumer. Clinicians involved in error, along with their colleagues, also suffer when harm occurs as a result of error. Most importantly, the consumer and/or their family suffer, including if the facts of an error are not fully disclosed. This research aims to describe the complexity of safety climate amongst nurses working in rural clinical settings. It focuses on the nature of this complexity in relation to nurses' views of reporting medication error. The framework for the research was underpinned by complexity science with health care viewed as a complex system where evidence and sense-making are forms of knowledge generation. A survey incorporating a safety attitudes questionnaire and a hypothetical medication error with multiple outcome scenarios (severe, moderate and near miss error) was used to collect data for this research. Variable analysis was undertaken along with case-based analysis using a configurational comparative method (CCM). This provided an additional means of analysing the data with each individual nurse considered a case. Variable analysis found differences in both views of reporting and disclosure as well as safety climate and teamwork factors amongst reporting compared with disclosure, severity of harm from the error, workplace setting and work role. The results from the case-based configurations of factors of safety climate present for the outcomes in each of these areas also demonstrated complexity existed in the relationship between the factors and views. Some of these configurations suggest common assumptions made about culture and error reporting are not fully consistent with an outcome that an error would always be viewed as reported or acknowledged by each individual nurse. These assumptions need to be rethought, particularly those surrounding positive safety climate factors as being causal for improvements in error reporting and disclosure. The case-based results also had implications for the concept of resilience. They suggest a need for more focus upon why error is reported and disclosed rather than looking primarily at why it is not occurring. Error management should be regarded as an intervention for safe patient care rather than an outcome of positive safety climate. In this way resilience to safety climate may be achieved. Use of a configurational comparative method has provided for better understanding of safety climate and error within the complex and chaotic world in which health care delivery occurs. Shifting from a focus upon reductive approaches to research, that are driven by evidence, to one of expanding knowledge and sense-making helps with understanding the world of clinical practice where nurses work, and consumers receive health care. This informs both future research as well as the development of new theories for the delivery of safe patient care.